Provider Demographics
NPI:1255678967
Name:PANJWANI, MARIAM A (CRNA)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:A
Last Name:PANJWANI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARIAM
Other - Middle Name:
Other - Last Name:SULTAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2312 PALMETTO WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1456
Mailing Address - Country:US
Mailing Address - Phone:214-680-7860
Mailing Address - Fax:
Practice Address - Street 1:2304 JANNA WAY
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1509
Practice Address - Country:US
Practice Address - Phone:214-680-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX736856363L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8791UFOtherBCBS
TX273613YKPFMedicare PIN